上海市社区慢性病健康管理信息系统建设及应用成效

Construction and effectiveness of the chronic disease health managemen information system in Shanghai communities

为支撑“以人为核心”慢性病健康管理业务工作的开展,上海市建设了社区慢性病健康管理信息系统,该系统通过信息登记管理和风险评估、慢性病筛查、患者评估、分类随访等功能为实现医防融合、医患协同的多种慢性病的全程、精准、高质量健康管理服务提供了高效的工具,有效推动了慢性病综合防治战略的实施和慢性病健康管理服务的深度转型。但该系统纳入管理的慢性病病种有待进一步增加、诊室环境的医生随访与家庭环境的自主管理交互融合有待增强,今后可进一步对系统进行病种整合和复合场景交互融合,以不断顺应慢性病防控的新形势、新挑战。

To support the"people-centered"chronic disease health management work,Shanghai has developed a community chronic disease health management information system.This system provides an efficient tool for achieving integrated medical care and disease prevention,as well as collaborative management between doctors and patients,through functions such as information registration and management,risk assessment,chronic disease screening,patient evaluation,and categorized follow-up.It delivers comprehensive,precise,and high-quality health management services for various chronic diseases,effectively promoting the implementation of comprehensive chronic disease prevention and control strategies and the transformative development of chronic disease health management services.However,the system currently requires the inclusion of a broader range of chronic diseases and the enhancement of interactive integration between clinic-based doctor follow-ups and home-based self-management.Future improvements may include the integration of additional disease types and the fusion of complex interaction scenarios to continuously adapt to the new situations and challenges in chronic disease prevention and control.